We want to better understand tobacco and vaping concerns among adults in our community. This survey is CONFIDENTIAL, and your honest feedback is appreciated. Persons who choose to include their name at the bottom of the survey may be eligible to receive a gift card incentive, subject to available funding.

Section 1: About You

1.What community do you live in?

Limon

Hugo

Genoa

Karval

Other (please specify)

2.What is your age group?

Under 18

18-24

25-34

35-44

45-54

55-64

65+

Section 2: Tobacco & Nicotine Use

3.Do you currently use any of the following?

Cigarettes

E-Cigs/ Vape

Chew/ Smokeless tobacco

Cigars

Nicotine Pouches

None

4.Have you tried to quit in the past year?

Yes

No

I don't use any products

5.IF yes, what stopped you from quitting? (select all that apply)

Stress

Cost of quit aids

Lack of support

Cravings/ withdrawl

Not Ready

Didn't know where to get help

N/A

Other (please specify)

Section 3: Awareness & Access

6.Are you aware of free quit resources, such as...

Colorado Quitline

Free Nicotine Replacement Therapy (patches, gum, etc.)

Local Counseling Support

I was not aware of these resources

7.Would you be interested in any of the following?

Free Quit Kits

Local Support Groups

Virtual/Text Based Support

Help at your Clinic

Information for Parents about Youth Vaping

No Interest

8.What makes quitting harder in a rural community?

Section 4: Community Impact

9.Do you believe youth vaping is a concern locally?

Yes, Major Concern

Somewhat

Not Really

Unsure

10.What tobacco-related resources would benefit our community most?

11.What tobacco concerns do you see most with youth in our community, if any?

Section 3: Incentive Collection

12.First & Last Name (for gift card incentive purposes only)

13.Mailing Address (to send gift card via mail if unable to collect same day)